Endocardial transvenous pacing in patients with surgically palliated univentricular hearts: A review on different techniques, problems and management

Fig. 1. Graphic illustration of different methods of endocardial pacing. A: Atrial lead in right atrial appendage and ventricular lead through the coronary sinus in atriopulmonary Fontan; B: Atrial lead in lateral atrial wall and ventricular lead through fenestration in lateral tunnel Fontan; C: Both atrial and ventricular lead through fenestration in extracardiac conduit Fontan; D: Ventricular lead through a fenestration created between floor of right pulmonary artery and atrium with a Brockenbrough needle in catheterization laboratory; E: Atrial and ventricular lead through venous collaterals after Fontan; F: Transhepatic leads through fenestration in extracardiac conduit Fontan following Kawashima shunt; G: Transhepatic lead through hepatic vein following total cavopulmonary Kawashima shunt; H: Ventricular lead through narrowed pulmonary valve in pulsatile Glenn shunt; I: Peratrial atrial and ventricular lead through a pursestring suture in right atrial wall.

Fig. 2. A percutaneous venous access through the hepatic vein into the atria using a 0.025″ guide wire(A) aided placement of a ventricular screw-in lead with a redundant loop in the atrium(B) and subsequently connected to a pulse generator(C) fixed in a subrectus pocket(D).

Fig. 3. A minimal access right anterolateral thoracotomy enabled placement of two peratrial sheaths(A) that enabled placement of atrial and ventricular screw-in leads. (B).

Fig. 4. The atrial and ventricular leads were advanced through a fenestrations using a steerable decapolar catheter telescoped in a coronary sinus peel-away sheath and finally screwed into the atrial appendage and ventricular apex respectively. (D).

Fig. 5. Following an angiogram to delineate the small tortuous venous collateral from left innominate vein to the coronary sinus(A), a steerable telescopic system guided placement of two endocardial leads(B) into the final position(C) to achieve dual chamber synchronous pacing.

Fig. 6. Combined epicardial and endocardial pacing. When epicardial ventricular lead failed due to lead fracture, it was replaced by an endocardial lead(A) placed inserted from left subclavian vein(B) and tunneled into the epigastric subrectus pocket (C)through the chest wall.

Fig. 7. When an extracardiac conduit Fontan had no fenestration(A), it was created with a transjugular Brockenbrough needle(B) and stented to create a fenestration from floor of right pulmonary artery to roof of the atrium(C).